When George Lai of Portland, Oregon, took his toddler son to a pediatrician last summer for a checkup, the doctor noticed a little splinter in the child’s palm. “He must have gotten it between the front door and the car,” Lai later recalled, and the child wasn’t complaining. The doctor grabbed a pair of forceps — aka tweezers — and pulled out the splinter in “a second,” Lai said. That brief tug was transformed into a surgical billing code: Current Procedural Terminology (CPT) code 10120, “incision and removal of a foreign body, subcutaneous” — at a cost of $414.
This is where healthcare practitioners and billing disconnect
As a healthcare practitioner you’re generally trained to use the most advantageous billing codes, or at least allude to procedures so that your billing staff can maximize them.
An example from mental health: I can bill code 90834 for a 16-52 minute psychotherapy session, or I can bill 90837 for 53+ minute. The reimbursement rates are sometimes wildly different ($75ish dollars vs $115ish dollars). So the typical 45 minute session gets padded by 8 minutes because by doing that I earn $40 dollars more per hour. Not nearly what this guy billed in a moment but it adds up quickly, especially for weekly sessions ($160/mo more is nothing to sneeze at)
But as a practitioner I don’t know what insurance you have. I don’t know where you’re at with your insurance. I don’t know what your situation is. And this can make all the difference
If you have a PPO plan my billing code doesn’t matter, you just pay your copay. If you have a high deductible and you’ve met your deductible you pay your coinsurance (usually 10-20%) so the difference is usually only a few dollars. But if you haven’t met your deductible? Now you’re paying the $40 difference out of pocket.
The rationalization from health care providers is that you should basically budget to meet your deductible, eg if you have health insurance with a $8,000 deductible you should budget at least that much for health spending each year. And to be fair this is how the insurance is supposed to work, but this is often poorly explained to people, many people who don’t have chronic illness don’t bother because they never reach their deductible, they’re frustrated that they’re paying several hundred dollars a pay in premiums and still expected to pay thousands more in deductibles and coinsurances, etc.
so then as a practitioner I’m put in an awkward spot: do I maximize billing to keep my practice making money or do I cut corners on billing to save clients the pain of their own insurance? It’s not my fault the system is setup in this way. Do I bill the people who have PPOs and met deductibles and give a break to those who haven’t met their deductibles? That’s not really fair and may also get me in trouble with insurance, especially in these times where insurance companies are starting to increasingly use AI nonsense to look for suspect billing patterns. Do I stop taking insurance altogether? That fucks over poor people, not an option.
Also fwiw you could argue this doctor could just not bill that code. Physical health bills more than mental health for sure because of multiple codes per visit, add on codes, etc and that’s a big part of why they make more money but also keep in mind those practices generally take way more money to run. My practice is just me doing everything, even when I have employees. I do scheduling (the other clinicians handle their own scheduling), I do billing, I do credentialing, I do IT, etc. I also have minimal overheads because I do telehealth only at this point.
generally the complexity involved with physical health means you’re at least hiring an office manager (~40-50k/yr) and billing support (~5-7% of earnings, or internal and another $40-50k/yr). And physical health for many specialties requires physical space, and a medical practice requires a decent amount of it. Commercial rentals are absurd and as soon as landlords realize you’re healthcare they fleece you because they realize it’s a pain in the ass for you to move.
That sounds like “I’m just following orders.” to me.
Yeah, maybe, but it’s also a serious question that comes up in practice
Why should I personally subsidize your care because the system is bullshit? Why should the burden be placed on me? I already have a sliding scale for low income patients (that gives me no tax benefit whatsoever), I already write off thousands in bad debt rather than ruin people’s credit by sending them to debt collection (which is income I just don’t receive, to be clear).
When a fix isn’t in place, isn’t proposed, and isn’t coming, what do you propose I do? Just not bill people? Reduce my already kind of shitty income further?
For the record I make about 50-60k a year and have 100k in student loan debt. Also given the nature of my work I have no benefits whatsoever so with that salary I have to self fund health insurance, vision, dental, retirement, days off, etc.
So again I propose what is the solution here? I can’t work for free and at a certain income point the job no longer becomes feasible. I have to do what I can within this deeply flawed system to be able to provide care while still providing an income for myself because if I don’t do that I will starve to death. Thanks for comparing me to a nazi though
Have you investigated direct primary care programs as a “subscription” model to the services you provide? Like what’s described here:
https://www.aafp.org/about/policies/all/direct-primary-care.html
I’m not a physician or in medicine at all, so this is genuine curiosity on my part for an idea that was recently described to me. I’m looking for feedback from someone that lives inside the system on if they even think something like this is feasible or has potential to succeed.
I’ve investigated this in that I’ve polled some of clientele on the idea and the general feedback I’ve gotten is some interest but generally rejection
I think the issue is twofold:
One: I’m mental health, and for any specialization a subscription model potentially doesn’t make sense. You may utilize our services heavily for a period then suddenly not at all or minimally.
Two, and the bigger one: most people polled did not have an interest in paying for such a thing when they already had insurance benefits via their workplace. This is understandable and gets into a great deal of complexity. Decoupling insurance from jobs is often cited as a huge need and that obviously necessary. But additionally the current system only allowing changes to insurance annually really hampers this too.
Finally, one frustrating point on this topic is contractual obligations with insurers. If I implement a system like this and continue to take insurance as well I run into issues because of the above situations. If you have insurance and decide to subscribe instead, planning to potentially cancel your plan in 8 months when you can renew your benefits package, I can actually be penalized for billing you privately when I knew you were a subscriber of a plan I was in network for.
Not all insurances do this but a lot have this in their contractual agreements. It would jeopardize my ability to maintain network status for the clients I do take insurance for and potentially cost me tens of thousands in clawback payments if I were ever audited for being out of compliance.
Thank you for the detailed response.
I was aware that there were coverage contracts with insurance providers that could potentially get in the way of this, but I hadn’t really thought about the “I already have insurance, why buy this?” aspect, but it seems obvious in hindsight.
The sporadic usage of specialists, which I would qualify mental heath as one, also doesn’t necessarily lend itself to this model.
I think I stand with the majority of people in that all healthcare, of which mental health should be a substantial part, needs an overhaul in the U.S.
It’s the how that becomes the difficult part.
I think the ultimate problem is that it needs a collectivist solution and the people we’ve elected, who would need to architect such a thing, have consistently shown they have no interest in such a thing
Challenges all around though. People talk about “lobbyist money” and that’s certainly a major factor but there’s more to it than that. We have no social safety nets in the us. That’s why when Kamala proposed Medicare for all she proposed a two lane option that still had privatized plans (which would still enable so much administrative waste, but would at least be an incremental improvement in terms of reintroducing compulsory insurance and decoupling insurance from employment).
But to overnight create an actual socialized medicine program akin to the nhs would destroy hundreds of thousands of jobs overnight. It would also eliminate tens of billions of dollars of waste administrative spending and streamline so much stuff that I do, but it would be a nightmare to get political support for because anyone who works in medical billing, who works for Aetna, Cigna, anthem, etc, would see the writing on the wall. Some of their jobs would be recreated in whatever new system was made but the majority would be made redundant. that’s where we go back to the lack of a social safety net piece: the USA has an extremely poor track record here. And it’s not just overpaid ceos making 10 million a year, it’s thousands of administrators, claims adjusters, middle managers, etc, making 40-80k who would be thrown to the wolves